Zina Maria Almeida de Azevedo

Increased production of tumor necrosis factor-alpha in whole blood cultures from children with primary malnutrition

Because low tumor necrosis factor-alpha (TNF-alpha) production has been reported in malnourished children, in contrast with high production of TNF-alpha in experimental protein-energy malnutrition, we reevaluated the production of TNF-alpha in whole blood cultures from children with primary malnutrition free from infection, and in healthy sex- and age-matched controls. Mononuclear cells in blood diluted 1:5 in endotoxin-free medium released TNF-alpha for 24 h. Spontaneously released TNF-alpha levels (mean +/- SEM), as measured by enzyme immunoassay in the supernatants of unstimulated 24-h cultures, were 10,941 +/- 2,591 pg/ml in children with malnutrition (N = 11) and 533 +/- 267 pg/ml in controls (N = 18) (P < 0.0001). TNF-alpha production was increased by stimulation with lipopolysaccharide (LPS), with maximal production of 67,341 +/- 16,580 pg/ml TNF-alpha in malnourished children and 25,198 +/- 2,493 pg/ml in controls (P = 0.002). In control subjects, LPS dose-dependently induced TNF-alpha production, with maximal responses obtained at 2000 ng/ml. In contrast, malnourished patients produced significantly more TNF-alpha with 0.02-200 ng/ml LPS, responded maximally at a 10-fold lower LPS concentration (200 ng/ml), and presented high-dose inhibition at 2000 ng/ml. TNF-alpha production a) was significantly influenced by LPS concentration in control subjects, but not in malnourished children, who responded strongly to very low LPS concentrations, and b) presented a significant, negative correlation (r = -0.703, P = 0.023) between spontaneous release and the LPS concentration that elicited maximal responses in malnourished patients. These findings indicate that malnourished children are not deficient in TNF-alpha production, and suggest that their cells are primed for increased TNF-alpha production.

Associação entre ângulo de fase, PRISM I e gravidade da sepse

BACKGROUND AND OBJECTIVES: Phase angle (PA) is the difference between voltage and current and can be used as an indicator of body cell mass. Clinical studies show that low phase angle is associated with morbidity and mortality of critical patients. The purpose of this study was to know the relation between phase angle and the Pediatric Risk of Mortality I (PRISM I) score, associating this score with the severity of sepsis. METHODS: A transversal study was performed at the Pediatric Intensive Care Unit (PICU) in Instituto Fernandes Figueira. The patients were classified according to age, gender, sepsis severity, cause of respiratory failure, PRISM I score, multiple organ dysfunction syndromes (MODS). Electrical bioimpedance analysis (BIA) was performed in all patients. Phase angle was calculated directly from reactance (Xc) and resistance (R). AF = arc-tangent reactance/resistance x 180o/Pi. RESULTS: 75 patients (68 septic) were evaluated. The incidence of septic shock was 39.7%, severe sepsis 42.6% and sepsis 17.6%. There was no significative statistical difference between the mean values of BIA and the categories of PRISM I, MODS, or the length of stay the PICU. The PAs lowest values (1.5o-2.2o) were associated to the greatest PRISMs scores (> 30%). CONCLUSIONS: Pediatric critical patients show low phase angle values, which might have prognostic implication.

Pneumocephalus and Exophthalmos Secondary To Acute Sinusitis and Nasopharyngeal Oxygen Catheter

Pneumocephalus is a well-known complication of skull trauma, certain neurosurgical procedures, and sinus neoplasms.1,2 The association between pneumocephalus and infection is very rare, usually occurring in patients with mastoiditis, chronic otitis media, and sinusitis.1,3 In a recent report, pneumocephalus and exophthalmos developed secondary to administration of oxygen by a nasopharyngeal catheter in a patient without sinusitis.4 We describe an infant admitted for treatment of bacterial pneumonia and maxillary and ethmoid sinusitis, in whom pneumocephalus and right-sided severe exophthlalmos developed while the patient was receiving oxygen by a nasopharyngeal catheter.

Doença da arranhadura do gato por Bartonella quintana em lactente: uma apresentação incomum

This case study reports a typical clinical course of cat-scratch disease (CSD) in an infant without epidemiological data and presenting bilateral submandibular lymphadenopathy. The authors describe clinical course, ultrasound images, diagnosis and prognosis. Polymerase chain reaction (PCR) detected and identified B. quintana in lymph node samples. B. henselae currently thought to be the causative agent of CSD was not detected. The PCR assays for B. quintana and B. henselae should be available for the investigation of lymphadenopathy, even if the infant has not had either cat or dog contact.

Evaluation of sublingual microcirculation in children with dengue shock

OBJECTIVE: To report the sublingual microcirculation observed using Sidestream Dark Field imaging in two children with dengue shock. METHOD: Two children, aged 9 and 10 years, were admitted to the pediatric intensive care unit with dengue shock and multiple organ dysfunction. Sublingual microcirculation was assessed in each patient on the first and second days of shock and was assessed a final time when the patients were no longer in shock (on the day prior to extubation) using Sidestream Dark Field technology. The De Backer score and microvascular flow index were used for the analyses. RESULTS: Both patients had reduced perfused small vessel density in the first two days and showed predominantly intermittent or no microcirculation flow, as demonstrated by a low microvascular flow index. The blood flow in the large vessels was not affected. Prior to the extubation, the microvascular flow index had increased, although the perfused small vessel density remained diminished, suggesting persistent endothelial dysfunction. CONCLUSIONS: Severe microcirculation changes may be involved in the pathophysiological mechanisms that lead to the final stages of dengue shock, which is frequently irreversible and associated with high mortality rates. Microcirculatory monitoring may help elucidate the physiopathology of dengue shock and prove useful as a prognostic tool or therapeutic target.

Estudo de crianças com síndrome do desconforto respiratório agudo: correlação anatomoclínica radiológica

This retrospective study reviews cases of ARDS (Adult Respiratory Distress Syndrome) treated and followed up from October 1988 to December 1990 in the Pediatric Intensive Care Unit of Instituto Fernandes Figueira/FIOCRUZ, Brazil. Clinical, radiological and histopathological features were analyzed and correlated with well defined stages of the disease process. Out of 459 cases, 49 (11%) were selected for further study. In 11 cases, histopathological examination (4 biopsies and 8 autopsies) was performed and then classified into one of the following phases: exsudative, cellular proliferative and late fibrotic. The work emphasizes the need for further clinical and experimental studies in order to define the mechanisms and the impact of this Syndrome in the pediatric population.

Multiple bee stings, multiple organs involved: a case report

Accidents related to Africanized honey bees are growing globally and are associated with multiple stings owing to the aggressive behavior of this species. The massive inoculation of venom causes skin necrosis and rhabdomyolysis leading to renal failure. Anaphylactic manifestations are more common and are treated using well-defined treatment protocols. However, bee venom-induced toxic reactions may be serious and require a different approach. We report the case of a 3-year-old child, which would help clinicians to focus on the treatment approach required after an incident involving multiple bee stings.